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AUL — 0 1 - 92 MO N 1 5 7 4 .5 P 2 3 <br /> UBLIC HtALT'H SEti2YiCp <br /> > ,2ONMI>MAL HEALTH DngSto <br /> UBLIC RECORDS RELEASE P.EQtrM FORM <br /> INDIVIDUAL NAME PHONE NO (gIN3- ��t33 <br /> ADDRESS s <br /> A0ENC'Y NAME PHONE NO <br /> ADDRESS <br /> FILE ADDRESS EA FORCENISNT_ PATROF i <br /> Be +,low eAddis Se f h sFueklon s <br /> N r ' Ptv f LLXL�0ne s ,4. 4x.:L64). 961 '9x ASAP I <br /> M ` 4 <br /> C cw <br /> 'FI c4,' <br /> - d <br /> n 3 <br /> c <br /> ,k <br /> San Joaquin County Put Ile Health Services Environmental Health MvWon tiles are considered public records <br /> except for certain documents Identified In the dovetistnent Code and the State Water Code, <br /> Requests for public to rds or file reviews are subject to charges estabi4h6d In San Joaquin County Rules and <br /> Regulation Eavironme tat Health Permit Fees and Sarviees Charge!, <br /> Chatges for records or locumenU tequested by tubpoena ducee teeum are subject to change$ established to <br /> the Evidence Code. <br /> Photo copies of public locumew are subjeet to Public Records Policy 09J.-ML. <br /> SIGNATURE OFEQUESTINGPARTY��,,;,�� DATE 8 3LZqr. <br /> SIGNA'T'URE OF RELEASM OFFICIAL DATE _�...._— <br /> E14 00 14 (REV 1) <br /> r <br /> k <br /> s d tb :st Z6i16i80 WOad <br />